Phosphate control is still a great challenge in
chronic kidney disease (CKD), and in spite of the great improvements in dialysis techniques, achievement of the goals for
mineral metabolism control is still far from ideal.
Aluminum hydroxide has been largely abandoned due to the high risk of
aluminum toxicity, while the use of
calcium-based
phosphate binders may cause
hypercalcemia, overzealous parathyroid suppression, and extraskeletal calcification.
Sevelamer hydrochloride has been introduced as an efficient medication for
phosphate control, with a lower risk of
hypercalcemia and parathyroid suppression. Various clinical trials have compared the risk of
vascular calcification between
sevelamer and
calcium salts with inconsistent results. In spite of these inconsistencies, the
Kidney Disease Outcomes Quality Initiative (KDOQI) suggests non-
calcium phosphate binders as the preferred
phosphate binder in dialysis patients with severe vascular and/or other soft-tissue calcifications and in those with
hypercalcemia or
parathyroid hormone (PTH) <150 mg/dL. The
Kidney Disease Improving Global Outcome (KDIGO) limits the use of non-
calcium phosphate binders to patients with
hypercalcemia. Regarding the effect on mortality, the results of clinical trials are again inconsistent. The other important aspect of using
sevelamer is the issue of price, which is substantially higher than
calcium-based
phosphate binders. Reviewing the studies on economic aspects shows that
sevelamer increases quality-adjusted life-years (QALY) and possibly life years, with a higher cost compared to
calcium-based
phosphate binders. In conclusion,
sevelamer is a very useful
drug for
phosphate control, reduction of
hypercalcemia, and lessening the risk of adynamic
bone disease, with probable reduction in
vascular calcification and possible reduction in mortality rate. It has a higher economic burden on health care systems compared to
calcium-based
phosphate binders. This may affect its extensive use according to guideline recommendations, and will be influenced by local health care budgets and the decision of health care strategists.